A simple checklist prevents deaths after surgery, a large new study suggests

Hospitals in South Carolina that completed a voluntary, statewide program to implement the World Health Organization's Surgical Safety Checklist had a 22 percent reduction in post-surgical deaths. The study, set to publish in the August 2017 issue of Annals of Surgery, is one of the first to show a large-scale impact of the checklist on the general population.

Surgical care is an important part of global health development for managing injuries, cardiovascular disease and other ailments. However, surgical care requires careful coordination of a variety of skilled health-care providers in a complex infrastructure using specialized tools.

“Safety checklists are not a piece of paper that somehow magically protect patients, but rather they are a tool to help change practice, to foster a specific type of behavior in communication, to change implicit communication to explicit in order to create a culture where speaking up is permitted and encouraged and to create an environment where information is shared between all members of the team,” said Alex Haynes, lead author of the study, who is an assistant professor of surgery at Harvard Medical School and associate director for safe surgery at Ariadne Labs.

All South Carolina hospitals were invited to participate in a voluntary, statewide effort to complete a 12-step implementation program, part of the Safe Surgery South Carolina program. South Carolina Hospital Association, the Harvard T.H. Chan School of Public Health and Ariadne Labs collectively undertook the project and customized the checklist for local settings, conducting small-scale testing and observing and coaching teams on checklist performance.

A total of 14 hospitals completed the program, representing 40 percent of the total inpatient surgery population in the state. Researchers then compared the 30-day post-surgery mortality results between the checklist hospitals with those of the rest of the hospitals in the state. The report includes major inpatient surgical procedures from various specialties, such as neurological, cardiac and orthopedic surgery.

Researchers found that post-surgery death rates in the hospitals that completed the program was 3.38 percent in 2010, before the implementation of the checklist program. It fell to 2.84 percent in 2013 after the checklist program was implemented. In the 44 other hospitals in the state, mortality rate was 3.5 percent in 2010 and 3.71 percent in 2013, which translates to a 22 percent difference in mortality rates between the hospitals.

The 19-item checklist encourages surgical teams to discuss the surgical plan, risks and concerns. Most of the items are simple, such as “does the patient have a known allergy” or “is essential imaging displayed.” Following surgery, patients are at risk of complications and death from a variety of causes, such as infection and organ failure. The checklist ends with a requirement for a conversation among the surgeon, anesthetist and nurse about the patient's recovery and management plan. As a whole, the checklist items create an operating room communication culture that improves overall surgical care and safety before, during and after an operation, the researchers say.

One of the main limitations of the study is that is not a controlled study because it was done as a quality-improvement initiative rather than a research project, Haynes said. There may be other differences between the hospitals that completed the checklist program and those that did not that account for the improved survival rate. But the study builds on previous smaller studies showing that the checklist seems to improve outcomes for surgery patients.

“I'd like to see this type of collaborative in South Carolina lead to collaboratives elsewhere, where we would be able to leverage this knowledge to improve care for patients everywhere,” Haynes said.